Healthcare Provider Details

I. General information

NPI: 1093747933
Provider Name (Legal Business Name): FREDS STORES OF TENNESSEE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 HOLLYWOOD SC HWY 20
JACKSON TN
38301
US

IV. Provider business mailing address

4300 NEW GETWELL RD
MEMPHIS TN
38118-6801
US

V. Phone/Fax

Practice location:
  • Phone: 731-427-1444
  • Fax: 731-427-0385
Mailing address:
  • Phone: 901-238-2520
  • Fax: 901-365-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberC1656
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberC1656
License Number StateTN

VIII. Authorized Official

Name: RICKY CHAMBERS
Title or Position: VP
Credential: PHARMD
Phone: 901-238-2477